10.

2478/bjdm-2020-0028

L SOCIETY
BALKAN JOURNAL OF DENTAL MEDICINE ISSN 2335-0245

CA
GI
LO
TO
STOMA

The Role of Parental Education in the Dental Health

Behavior of Turkish Secondary School Children

SUMMARY Fatih Karaaslan1, Ahu Dikilitaş1, Tuba Yiğit2,

Background/Aim: Parents are usually the major factor influencing Şerife Esra Kurt1
children’s development of routine oral health behavior. A higher education 1 Department of Periodontology, Faculty of

level of the parents is generally associated with having a more positive Dentistry, Usak University, Usak, Turkey
2 Department of Pedodontics, Faculty of
influence on their children’s health habits and motivation to maintain
healthy dentition. From this perspective, the aim of the present study was Dentistry, Usak University, Usak, Turkey
to investigate the frequency of certain habits influencing dental health, such
as toothbrushing, regular visits to the dentist, and changing toothbrushes,
in a group of Turkish secondary school children, and to explore its
relation to the education level of their mothers and fathers. Material and
Methods: The study consisted of the use of a questionnaire designed to
collect demographic information, oral health behavior of the children,
and the parents’ education level. Demographic characteristics and oral
health behavior of the children were asked of the children in a face-to-face
interview by one investigator. Only the parents’ education level was asked of
the children’s parents. Results: The mean age of the 444 children was 11.66
± 0.98. According to chi-square testing applied, there was a statistically
significant correlation between the parents’ education level and their
children’s dental visit frequency (p< 0.05), whereas there was no statistically
significant link between the parents’ education level and the frequency of
the children’s toothbrushing and replacing their toothbrushes (p> 0.05).
Conclusions: Irrespective of the education level of their parents, positive
oral health attitudes and behavior were not observed in Turkish secondary
school children. ORIGINAL PAPER (OP)
Key words: Child, Education, Parents, Oral Health Balk J Dent Med, 2020;52-59

Introduction teachers, play an important role in adopting a routine

Oral diseases are among the most common health
problems in children, and the preservation of healthy teeth
is a key factor in childhood1. Lack of oral hygiene is the
most significant etiological risk factor in the pathogenesis
of oral diseases; knowledge concerning the management
of oral diseases focuses on the role of oral health
behavior2. Regular visits to the dentist for checkups,
brushing teeth twice a day, and changing the toothbrush
every three months are required to preserve and manage
oral health in children3.
The family is the aspect of children’s environment
that most influences the development and establishment
of oral health behaviors4. Parents, the children’s first
of oral hygiene practices by transferring health-related
habits to their children5. Improvement in children’s oral
health depends on their parents’ knowledge, attitude and
education level2,6. Parental education is among the most
commonly-used measures of socioeconomic condition
in epidemiological studies on children’s oral health
outcomes7,8. Parents with more education have a more
positive attitude regarding their children’s oral health
and pay more attention to maintaining their children’s
healthy dentition. Lower-educated parents have been
shown to pay less attention to their children’s oral care
habits and regular dentist visits9,10. Studies in developed
countries have demonstrated the relationship between
parents’ education level and their children’s oral health
Balk J Dent Med, Vol 24, 2020 Parental Education 53

behaviour10–12, but there is insufficient literature on the
oral health influence of parents in developing countries.
In Turkey, oral epidemiological data on schoolchildren
are scarce; we lack evidence for assessing the association
between parental education and the development of good
oral hygiene skills in children.
From this standpoint, the aim of the present study was
to investigate the frequency of certain behavior influencing
dental health, such as toothbrushing, regular dental visits,
and toothbrush changing, in a group of Turkish secondary
school children and to evaluate its association with the
education level of their mothers and fathers.
were presented as mean and standard deviation, and the
level of statistical significance was set at 0,05.
Results
A total of 444 children, 174 (39.2%) boys and 270
(60.8%) girls, were included in the study. The age of
the participants ranged from 10 to 14, with a mean age
of 11.66 ± 0.98. The age and gender distributions of
participants are shown in Table 1.

Table 1. The age and gender distruption of children

Material and Methods   Gender n (%) mean±sd.

Male 174 (39.2) 11.59±1.08
A total of 444 children (270 girls and 174 boys) Age Female 270 (60.8) 11.700.92
between 10 and 14 years of age were included. The Total 444 11.66±0.98
study was conducted in the Usak University Faculty of
Dentistry, the only public dental school in Usak, serving a Children who brush their teeth twice or more daily
population estimated at about half a million, in accordance accounted for 40.5%, while 3.4% reported having no
with the ethical standards established by the Declaration brushing habit; 6.1% of the children had used the same
of Helsinki. Written informed consent was reviewed toothbrush for years, and 62.8% reported going to the
and approved by the University’s Ethics Committee and dentist only for pain or an emergency. Parents had taught
signed by all children and their parents. 81.75% of the children their toothbrushing skills, while
The study consisted of a questionnaire designed 8.78% of children learned toothbrushing from their
to gather the demographic information, oral health teachers. Data on the children’s oral health behavior are
behavior of the children, and the parents’ education levels. listed in Table 2.
Demographic characteristics and oral health behavior of the
children and related questions were asked of the children Table 2. The oral health behaviour of children
in a face-to-face interview by one investigator. Only the
parents’ education level was asked of the children’s parents   n %
in a face-to-face interview by another investigator who was no brushing 15 3.4
blind to the children’s oral health behaviors. once a week 48 10.8
Tooth brushing
The questions concerning oral health behaviors were once every three or four days 63 14.2
frequency
chosen from questionnaires used in previous studies5,7,10,13. once daily 138 31.1
Possible options for reporting toothbrushing frequency twice or more daily 180 40.5
were twice or more daily, once daily, once every three using the same brush for years 27 6.1
Tooth brush
or four days, once a week, or no brushing. The possible every year 84 18.9
changing
options for dental visit frequency were every six months, every six months 123 27.7
frequency
every year, only for an emergency or pain, or had never every three months 210 47.3
visited a dentist previously. Options for the frequency of never visit before 66 14.9
changing the toothbrush were every three months, every Dental visit only emergency and pain 279 62.8
six months, every year, or had been using the same brush frequency every year 27 6.1
for years. From whom the children had learned to brush every six months 72 16.2
included parents, teachers, dentists, or others. parents 363 81.75
From whom
Parents’ education level was differentiated as primary teachers 39 8.78
children had
school, secondary school, high school, or university. dentists 18 4.05
learned to brush
Version 17.0 of the Statistical Package for the Social others 24 5.42
Sciences (SPSS) was used for data analysis. Kolmogorov–
Smirnov and Shapiro–Wilks tests were used to confirm the The mothers’ education level was primary school for
normality of the data. The relationship between parents’ 37.8% of the children, while only 8.8% of the mothers’
education level and the frequency of toothbrushing, education level was university. The fathers’ education
toothbrush replacement, and dental visits was examined level was secondary school for 33.8% and 20.3% of the
using the chi-square test, which was also used to compare fathers’ education level was university. Education level
the oral health behaviors of girl versus boy students. Data distributions of mothers and fathers are given in Table 3.
54 Fatih Karaaslan et al. Balk J Dent Med, Vol 24, 2020

Table 3. Education level of mothers and fathers There was no statistically significant correlation
Education level n %
between the mothers’ and fathers’ education level and
Primary school 168 37.8 the children’s toothbrushing or toothbrush changing
Education level of Secondary school 138 31.1 frequencies (p> 0.05) (Tables 4 and 5).
mothers High school 99 22.3 There was a statistically significant correlation
University 39 8.8
between the mothers’ and fathers’ education levels and
Primary school 72 16.2
Education level of Secondary school 150 33.8 the frequency of the children’s dental visits (p< 0.05)
fathers High school 132 29.7 (Table 6). As the education level of the mother and father
University 90 20.3 increased, the frequency of going to the dentist increased.

Table 4. The education level of parents and children’s tooth brushing frequency
Mother education level Chi- Father education level Chi-
  primary secondary p secondary p
school school
high school university square primary school
school
high school
university
square
n 9 3 0 3 6 3 6 0
no brushing
%R 60.0% 20.0% 0.0% 20.0% 40.0% 20.0% 40.0% 0.0%
%C 5.4% 2.2% 0.0% 7.7% 8.3% 2.0% 4.5% 0.0%
n 18 21 6 3 9 18 9 12
once a week % R 37.5% 43.8% 12.5% 6.3% 18.8% 37.5% 18.8% 25.0%
%C 10.7% 15.2% 6.1% 7.7% 12.5% 12.0% 6.8% 13.3%
Monte Carlo

Monte Carlo
Tooth once every n 24 15 21 3 12 24 15 12
brushing three or %R 38.1% 23.8% 33.3% 4.8% 0.888 19.0% 38.1% 23.8% 19.0% 0.485
frequency four days %C 14.3% 10.9% 21.2% 7.7% 16.7% 16.0% 11.4% 13.3%
n 51 39 33 15 12 54 33 39
once daily % R 37.0% 28.3% 23.9% 10.9% 8.7% 39.1% 23.9% 28.3%
%C 30.4% 28.3% 33.3% 38.5% 16.7% 36.0% 25.0% 43.3%
n 66 60 39 15 33 51 69 27
twice or
%R 36.7% 33.3% 21.7% 8.3% 18.3% 28.3% 38.3% 15.0%
more daily
%C 39.3% 43.5% 39.4% 38.5% 45.8% 34.0% 52.3% 30.0%

%R: percentage of frequencies in the row; %C: percentage of frequencies in the column; n: sample size

Table 5. The education level of parents and children’s tooth brush changing frequency
Mother education level Chi- Father education level Chi-
  primary secondary p secondary p
school school
high school university square primary school
school
high school
university
square

using the n 15 9 3 0 9 12 3 3
same brush %R 55.6% 33.3% 11.1% .0% 33.3% 44.4% 11.1% 11.1%
for years %C 8.9% 6.5% 3.0% .0% 12.5% 8.0% 2.3% 3.3%
n 33 24 21 6 6 27 27 24
every year %R 39.3% 28.6% 25.0% 7.1% 7.1% 32.1% 32.1% 28.6%
Monte Carlo

Monte Carlo

Tooth
brush %C 19.6% 17.4% 21.2% 15.4% 8.3% 18.0% 20.5% 26.7%
0.842 0.667
changing n 45 48 21 9 21 45 39 18
frequency every six %R 36.6% 39.0% 17.1% 7.3% 17.1% 36.6% 31.7% 14.6%
months
%C 26.8% 34.8% 21.2% 23.1% 29.2% 30.0% 29.5% 20.0%
n 75 57 54 24 36 66 63 45
every three
%R 35.7% 27.1% 25.7% 11.4% 17.1% 31.4% 30.0% 21.4%
months
%C 44.6% 41.3% 54.5% 61.5% 50.0% 44.0% 47.7% 50.0%

%R: percentage of frequencies in the row; %C: percentage of frequencies in the column; n: sample size
Balk J Dent Med, Vol 24, 2020 Parental Education 55

Table 6. The education level of parents and children’s dental visit frequency
Mother education level Father education level
  Chi- p Chi- p
primary school
secondary
high school square primary school
secondary
high school square
school university school university

n 27 27 13 0 12 30 9 15
never visit %R 40.9% 40.9% 18.2% 0.0% 18.2% 45.5% 13.6% 22.7%
before
%C 16.1% 19.6% 12.1% 0.0% 16.7% 20.0% 6.8% 16.7%
n 111 90 60 18 51 87 93 48
only
emergency %R 39.8% 32.3% 21.5% 6.5% 18.3% 31.2% 33.3% 17.2%

Monte Carlo

Monte Carlo
and pain
Dental visit %C 66.1% 65.2% 60.6% 46.2% 70.8% 58.0% 70.5% 53.3%
frequency 0.011* 0.049*
n 9 6 6 6 3 15 3 6
every year %R 33.3% 22.2% 22.2% 22.2% 11.1% 55.6% 11.1% 22.2%
%C 5.4% 4.3% 6.1% 15.4% 4.2% 10.0% 2.3% 6.7%
n 21 15 21 15 6 18 27 21
every six %R 29.2% 20.8% 29.2% 20.8% 8.3% 25.0% 37.5% 29.2%
months
%C 12.5% 10.9% 21.2% 38.5% 8.3% 12.0% 20.5% 23.3%
*p<0.05; %R: percentage of frequencies in the row; %C: percentage of frequencies in the column; n: sample size

Table 7. gender difference of oral health behaviour

Gender
  Chi-square p
Boy Girl
n 9 6
no brushing %R 60.0% 40.0%
%C 5.2% 2.2%
n 30 18
once a week %R 62.5% 37.5%
%C 17.2% 6.7%
n 21 42
Tooth brushing frequency once everydaysthree or four %R 33.3% 66.7% 14.443 0.006*
%C 12.1% 15.6%
n 72 66
once daily %R 52.2% 47.8%
%C 41.4% 24.4%
n 42 138
twice or more daily %R 23.3% 76.7%
%C 24.1% 51.1%
n 12 15
using the same brush for % R 44.4% 55.6%
years
%C 6.9% 5.6%
n 21 63
every year %R 25.0% 75.0%
Tooth brush changing %C 12.1% 23.3%
frequency 7.596 0.055
n 36 87
every six months %R 29.3% 70.7%
%C 20.7% 32.2%
n 105 105
every three months %R 50.0% 50.0%
%C 60.3% 38.9%
n 33 33
never visit before %R 50.0% 50.0%
%C 19.0% 12.2%
n 102 177
only emergency and pain %R 36.6% 63.4%
Dental visit frequency %C 58.6% 65.6% 2.706 0.439
n 15 12
every year %R 55.6% 44.4%
%C 8.6% 4.4%
n 24 48
every six months %R 33.3% 66.7%
%C 13.8% 17.8%
*p<0.05; %R: percentage of frequencies in the row; %C: percentage of frequencies in the column; n: sample size
56 Fatih Karaaslan et al.
There were no statistically significant correlations
between the gender of the children and the frequencies of
dental visits and toothbrush changing (p> 0.05) (Table 7),
but there was a significant association between gender and
toothbrushing frequency (p< 0.05) (Table 7). The girls’
toothbrushing frequency was significantly higher than the
boys’.
Discussion
Oral health is clearly related to behavior;
the prevalence of oral diseases can be diminished
considerably with improvements in attitude and the
oral hygiene habits of children, which depend on the
awareness and knowledge of their parents14. The attitudes
toward oral health of parents, the primary role models
for developing children’s oral health behavior, depend
on their education2,15. Therefore, parents’ education level
should be considered a powerful social force to ensure the
oral well-being of children. For this reason, our objective
was to examine the effects of fathers’ and mothers’
education level on the oral health behavior of secondary
school children.
Generally, children need help and encouragement
brushing their teeth until the age of 10, as supported
by a study by Sandström et al.16. Eleven-year-old
children were found by Pujar et al.17 to have the ability
to effectively brush their teeth. Considering these
parameters, secondary school students (ages 10–14) are of
an age at which they can brush their teeth on their own
without help from their parents, and were thus included
in our study. In addition, most previous studies have
examined the relationship between the mothers’ education
level and the oral health behavior of children18-21, but the
fathers’ education level has rarely been examined10. In this
study, the education levels of both mothers and fathers
were examined.
Toothbrushing is considered a fundamental self-
care behavior for the maintenance of oral health, and
brushing twice a day is widely recommended to preserve
good oral health22. In the present study, the frequency
of brushing twice daily was reported by 40.5% of the
children. This percentage is markedly lower than in
Sweden (79%), Denmark (78%) and Switzerland (85%),
but is similar to percentages in Lithuania (39%) and
Finland (40%)23. No statistically significant correlation
between the mothers’ and fathers’ education level and
the children’s toothbrushing frequency was found. This
did not agree with previous findings reporting that
children’s toothbrushing frequency was directly linked to
the educational level of their parents24. Although higher
educational levels may make people more receptive to
health education programs25, the results indicated that
children in Turkey need more support for achieving
Balk J Dent Med, Vol 24, 2020
efficient oral health behavior, regardless of their parents’
education level. In particular, we highlight these possible
explanations. First, the knowledge of parents in Turkey
did not translate into behavior. This disparity between
improved knowledge and changing behavior has also
been reported by other authors26. Second, many parents
today experience a stressful daily life, and this may lead
to a more lenient attitude towards children skipping
toothbrushing. This is consistent with a Norwegian study
by Skeie et al.27.
It is generally recommended that toothbrushes
should be change after three months of use in order to
maintain their efficacy28. In this survey, 47.3% of the
children changed their toothbrushes every three months,
whereas 6.1% of them had used the same toothbrush for
years. The average annual usage of brushes per capita in
Turkey is 0.3, while the average annual usage rate in the
UK is 2.4 and 2.5 in Sweden29. The frequency of changing
toothbrushes in Turkey is lower than in developed
countries. No statistically significant link was found in
this study between the mothers’ and fathers’ education
level and children’s toothbrush changing frequency. These
results are not in line with previous studies that reported
that people with a higher level of education tend to change
their toothbrushes more often24,30. This may suggest that
an oral health culture has not been developed in Turkey
due to lower levels of parental oral health literacy and
culture. Previous studies have revealed that dental
attitudes and behaviors depend on cultural factors9,11. It
is essential to understand the oral health beliefs of parents
and strive to change the customs that are inconsistent with
scientific knowledge, in order to overcome socio-cultural
barriers in promoting good oral health in children31.
Regular dentist visits at least every six months are
important for preserving good oral health32. Most children
use dental services only in case of pain or an emergency,
which is in line with other studies33. Only 16.2% of the
children attended regular checkups every six months.
This rate is lower than many developed countries,
such as Denmark, Norway, and Sweden34. This study
indicated that Turkish children use dental services only
in cases of serious disorders causing physical discomfort.
The reasons for avoiding regular visits may include
apprehension, lack of knowledge about the importance
of visiting the dentist regularly, difficulty of accessibility
to dental clinics, time shortage, and cultural beliefs
associated with dental treatment. Statistically significant
correlations between the parents’ education level and the
children’s dental visit frequency were found in this study.
As the education level of parents increased, the frequency
of children going to the dentist rose. This is in agreement
with previous studies that reported the frequency of
utilization of dental services being higher in the children
of parents with high educational status35.
In the current research, it was observed that as the
education level of the mother and father increased, the
Balk J Dent Med, Vol 24, 2020
frequency of toothbrushing and changing toothbrushes
was not affected, although the frequency of going to
the dentist rose. This may be related to “knowledgeable
but defensive” oral health attitudes of Turkish mothers
and fathers, even if their education levels are high8.
The knowledgeable but defensive attitude is one of
five prevailing attitudes identified, that is, parents who
are aware of why and how to apply healthy dental
behavior but report being too busy to put it into practice.
Although these parents consider having healthy teeth
important, they prefer not to argue with their children
over toothbrushing due to a busy life and other things
having higher priority. Therefore, it is very important
for their children to see a dentist regularly for checkups
and treatment. This attitude stems from an avoidance
of arguing about toothbrushing with their child. It may
be related to the cultural beliefs of Turkish parents, and
motivating these parents may be necessary to prevent
oral disease in their children8,36 .
The triangle of parents, schoolteachers, and the
dentist plays an important role in the preservation
and improvement of children’s oral health behavior.
Schoolteachers are an important key for influencing
children’s oral health behaviour37. Children can be
educated by schoolteachers while their oral health
habits are developing because they spend considerable
time in school37. Only 8.78% of children reported that
they learned toothbrushing from their schoolteachers.
This may indicate that teachers have poor oral health
knowledge, skills, and motivation, in accordance with
other studies finding that some teachers had poor levels
of motivation and behavior related to oral health38. The
dentist can have significant influence in the process of
oral health education. The role of the dentist is essential
in educating parents and children about the importance
of oral health and adequate preventive measures to
preserve good oral health39. Only 4.05% of the children
stated that they learned toothbrushing from dentists. This
may be the result of children not having regular dental
visits, as well as the fact that dentists give priority to
treatment practices rather than focusing on preventive
dentistry.
When the oral health behaviors of girls and boys
were compared, regardless of the education level of
the parents, the frequency of toothbrushing was higher
in girls, but there was no significant difference in the
frequency of toothbrush changing and visiting the dentist.
This is in line with results from other countries that
confirm that toothbrushing is less frequent among boys
than girls in most European countries, except France12,23.
This suggests that girls are more concerned about their
oral health than boys and practice more health-directed
behaviors than boys12.
This study has certain limitations. First, the research
relied on self-reported data that may change depending
on cultural differences and environmental factors. On the
Parental Education 57
other hand, dental self-reports have high clinical validity
and a high level of concordance between children and
parents40. Second, the sample size was small and may
not have been representative of all secondary school
children in Turkey. Third, the questionnaire was chosen
from questionnaires used in previous studies and not
previously pilot-tested, because it was considered
that the questions were simple and would be readily
understood.
Conclusions
This study provides evidence that a high level of
education of the parents does not directly contribute
to positive oral health attitudes and behavior of their
children. Adequate support cannot be provided from
only teachers and dentists in developing children’s oral
health behaviors. Family and school-based education
programs are needed to develop positive behaviors in
children. Further research with a larger sample and over a
longer period is essential for a better understanding of the
influence of parents’ education on secondary students’ oral
health behavior and associated factors.
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Conflict of Interests: Nothing to declare.
Financial Disclosure Statement: Nothing to declare.
Human Rights Statement: All the procedures on humans were
conducted in accordance with the Helsinki Declaration of 1975,
as revised 2000. Consent was obtained from the patient/s and ap-
proved for the current study by national ethical committee.
Animal Rights Statement: None required.
Received on March 23, 2020.
Revised on Jun 1, 2020.
Accepted on Jun 20, 2020.
Correspondence:
Fatih Karaaslan
Department of Periodontology
Faculty of Dentistry, Usak University, Usak Turkey.
E-mail: fatih.karaaslan@usak.edu.tr